Sanchez et al. BMC Public Health 2011, 11(Suppl 2):S4
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REVIEW
Open Access
Capacity-building efforts by the AFHSC-GEIS
program
Jose L Sanchez1*, Matthew C Johns1, Ronald L Burke1, Kelly G Vest1, Mark M Fukuda1,2, In-Kyu Yoon2,
Chanthap Lon2, Miguel Quintana3, David C Schnabel4, Guillermo Pimentel5, Moustafa Mansour5, Steven Tobias6,
Joel M Montgomery7, Gregory C Gray8, Karen Saylors9, Lucy M Ndip10, Sheri Lewis11,
Patrick J Blair12, Paul A Sjoberg13, Robert A Kuschner14, Kevin L Russell1, David L Blazes1,
the AFHSC-GEIS Capacity Building Writing Group14,15,16,17,18,19,20,21,22,23,24,25
Abstract
Capacity-building initiatives related to public health are defined as developing laboratory infrastructure,
strengthening host-country disease surveillance initiatives, transferring technical expertise and training personnel.
These initiatives represented a major piece of the Armed Forces Health Surveillance Center, Division of Global
Emerging Infections Surveillance and Response System (AFHSC-GEIS) contributions to worldwide emerging
infectious disease (EID) surveillance and response. Capacity-building initiatives were undertaken with over 80 local
and regional Ministries of Health, Agriculture and Defense, as well as other government entities and institutions
worldwide. The efforts supported at least 52 national influenza centers and other country-specific influenza,
regional and U.S.-based EID reference laboratories (44 civilian, eight military) in 46 countries worldwide. Equally
important, reference testing, laboratory infrastructure and equipment support was provided to over 500 field sites
in 74 countries worldwide from October 2008 to September 2009. These activities allowed countries to better meet
the milestones of implementation of the 2005 International Health Regulations and complemented many initiatives
undertaken by other U.S. government agencies, such as the U.S. Department of Health and Human Services, the
U.S. Agency for International Development and the U.S. Department of State.
Background
Capacity building, as it applies to health in this context,
can be accomplished through strengthening health
systems for delivery of medical care, pursuing medical
research initiatives to answer important local or regional
health questions, or supporting public health disease surveillance to prioritize which diseases are affecting relevant populations. Within this context, global public
health capacity building can be defined as developing
laboratory infrastructure, strengthening host-country disease surveillance initiatives, transferring technical expertise and training personnel. Disease surveillance is often
the first step in improving public health because it
attempts to quantify needs and allocate scarce assets in
* Correspondence: Toti.Sanchez@us.army.mil
1
Armed Forces Health Surveillance Center, 503 Robert Grant Avenue, Silver
Spring, MD 20910, USA
Full list of author information is available at the end of the article
resource-limited settings, in addition to detecting potential outbreaks of disease.
Though not a new concept, capacity building has
enjoyed renewed prominence as the world endeavors to
meet requirements of International Health Regulations
2005 (IHR (2005)) [1]. Article 5 of the regulations requires
that all countries be able to detect, assess, notify and
report on public health issues of international significance
and control any potential public health event of international concern by 2012. Some countries are capable now,
but most are not and will not be compliant by the deadline
unless a significant improvement in local capacity occurs.
In general, for capacity building to be successful in the
long term, efforts must not be undertaken quickly and
need to be implemented through a concerted unified
effort, achieving steady, sustainable and measurable progress over time, with the eventual goal being independence
from the provider of the capability.
© 2011 Sanchez et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Sanchez et al. BMC Public Health 2011, 11(Suppl 2):S4
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In 2007, the Government Accountability Office
issued a report describing the global infectious disease
capacity-building efforts of U.S. government (USG)
entities [2]. At the time, three USG entities were identified as providing capacity building for emerging
infectious diseases (EID), including the U.S. Centers
for Disease Control and Prevention (CDC), the U.S.
Agency for International Development and the Department of Defense’s Global Emerging Infections Surveillance and Response System (DoD-GEIS). Their efforts
included laboratory-based disease surveillance, development and testing of diagnostics, and training such as
Field Epidemiology Training Programs, the international version of the famed Epidemic Intelligence Service [3]. Currently, many other USG agencies are
engaged in building disease surveillance capacity,
including the U.S. Department of State, the Defense
Threat Reduction Agency and the U.S. National Institutes of Health [4]. In addition, numerous state, nonstate and non-governmental organizations, such as the
Bill and Melinda Gates Foundation, the World Bank
and Médecins sans Frontières, contribute substantially
to capacity-building efforts around the world [5-7].
With the establishment of the Armed Forces Health
Surveillance Center (AFHSC) in late 2008, the DoDGEIS program was transitioned to a division and
renamed “AFHSC-GEIS”; however, its mission of working to promote and facilitate national and international
preparedness for EID was maintained. Strengthening of
U.S. military and host-country disease surveillance and
public health laboratory capacity represents a critical
step for contributing to compliance with the IHR (2005)
detection, reporting and response requirements. During
2009, capacity-building efforts were undertaken in a
variety of formats, including enhancement of diagnostic
capabilities, expansion of surveillance for militarily relevant infectious and tropical diseases, and deployment of
electronic surveillance platforms. These efforts were
coordinated with local host-country health officials and
geographic Combatant Commands to ensure they
addressed country and regional medical priorities as
well as to ensure better surveillance and response to disease outbreaks and EID threats to U.S. forces abroad.
These efforts focused on influenza and other respiratory
diseases, malaria, dengue and other vector-borne illnesses, acute diarrheal diseases, antimalarial and antimicrobial resistance, sexually transmitted diseases, and
bacterial wound infections.
Accomplishments
Laboratory infrastructure development
Capacity-building initiatives continued to represent a
major component of AFHSC-GEIS contributions to worldwide EID surveillance and response activities. Inadequate
Page 2 of 9
laboratory capacity in developing countries has been
termed the “Achilles’ heel” of global efforts to combat
infectious diseases [8]. Thus, many AFHSC-GEIS sponsored activities in capacity building were directed at
improving existing infrastructure by renovating current
laboratory facilities, furnishing new scientific equipment,
and provisioning new or enhanced diagnostic testing systems at overseas U.S. DoD facilities, as well as U.S.-based,
DoD influenza reference laboratories, which serve as regional reference laboratories, and host-country laboratories.
Efforts were coordinated with over 80 local and regional Ministries of Health, Agriculture and Defense, as
well as other government officials and institutions
worldwide in 74 countries. A total of 52 National Influenza Centers (NICs) and other country-specific influenza and EID reference laboratories (44 civilian, eight
military) were supported in 46 countries (Table 1). The
efforts included support to laboratories in eight regions
of the world. Sub-Saharan (east, central and west) Africa
were the regions with the most major laboratory capacity-building efforts (in 14 countries), consistent with
the identified needs of this region relative to the world,
especially as it relates to influenza [9,10]. Among all
infrastructure and capacity-building projects (Table 2),
the majority supported primarily human health entities
(in 67 countries); however, projects also supported animal health entities for zoonotic diseases in eight countries. Training efforts are mentioned, but are presented
in detail elsewhere in this supplement [11].
One of the most notable AFHSC-GEIS accomplishments
in fiscal 2009 was the establishment of two new biosafety
level-3 (BSL-3) laboratory suites within DoD reference
laboratories. The Armed Forces Research Institute of
Medical Sciences (AFRIMS) in Bangkok, Thailand, completed the first laboratory, which the United States certified and commissioned on July 8, 2009. The suite was
officially inaugurated September 16, 2009 and began
immediately supporting work in avian and pandemic influenza monitoring, including culture and molecular sequencing capability (Figure 1). This BSL-3 laboratory
constitutes the first DoD-certified laboratory of its kind in
the region and provides the World Health Organization
(WHO), Thailand and other countries in Southeast Asia
with a much-needed high-containment capability to conduct research and assist with outbreaks involving select
human and animal bacterial and viral strains.
The Naval Health Research Center (NHRC) opened a
second BSL-3 (agriculture-enhanced) laboratory suite in
late 2009. The facility allows work with zoonotic influenza strains submitted by AFHSC-GEIS partners around
the world, including development of new virus neutralization testing capabilities against H5N1 and other highly
pathogenic avian influenza strains. Additionally, two
BSL-2 laboratories were also established at the Cameroon
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Table 1 2009 Major Laboratory Capacity-Building Initiatives by Geographic Region
Geographic Region
Major Laboratory Capacity Building Initiative
Southeast Asia
NIC & military influenza lab equipment, reagent & training support; EID
laboratory diagnostics & disease surveillance systems
Countries Supported
Far East
NIC & military influenza lab equipment & reagent support; EID lab
proficiency & equipment support
East & Central Africa
NIC & VHF lab equipment, reagent & training support; EID laboratory
diagnostics
West Africa
NIC & MoH influenza lab equipment, reagent & training support; VHF lab
diagnostics & military EID lab diagnostic testing capacity
Benin, Burkina Faso, Cote d’Ivoire, Ghana,
Liberia, Mali, Niger, Nigeria, Sierra Leone, Togo
North Africa, Middle
East & Southwest Asia
NIC lab equipment, reagent & training support
Afghanistan, Egypt, Iraq, Jordan, Kuwait, Oman,
Pakistan, Sudan, Syria
Central Asia
EID & influenza lab equipment, reagent & training support
Europe
Central & South
America
Military & academic influenza lab equipment, reagent & training support
NIC & MoH influenza lab equipment, reagent & training support;
leishmania military reference lab equipment, reagent & training support
Bhutan, Cambodia, Lao People’s Democratic
Republic, Nepal, Singapore, Thailand
Japan, Korea, Philippines
Cameroon, Kenya, Tanzania, Uganda
Azerbaijan, Georgia, Mongolia
Poland, Romania
Colombia, Ecuador, El Salvador, Guatemala,
Honduras, Nicaragua, Panama, Paraguay, Peru
Acronyms: NIC, national influenza center; EID, emerging infectious diseases; VHF, viral hemorrhagic fever; MoH, Ministry of Health.
Army Military Health Research Center, supported by
Global Viral Forecasting Initiative in Yaoundé and at the
University of Buea (Figure 2). Both facilities will greatly
improve the ability to conduct influenza and EID diagnostic work, as well as potentially advanced pathogen discovery work in hard-to-reach locations in Africa.
Efforts were also undertaken to improve laboratory
capability for global influenza surveillance and diagnosis,
especially regarding the novel A/H1N1 influenza pandemic. To this end, AFRIMS established viral/bacterial
pathogen culture and molecular diagnostic capability in
their Nepal detachment to support the National Public
Table 2 2009 Capacity-Building Initiatives by Major Regional AFHSC-GEIS Supported Partners and Type
Partner
(see text)
Type of Infrastructure/Capacity Building*
Centers/
Hospitals
Field
Sites
Countries*
AFRIMS
Influenza & malaria/MDR labs (KH, PH); enteric & influenza lab upgrade (NP, TH); blood culture
(NP); influenza testing (BT); influenza antiviral resistance (TH)
22
51
5
NAMRU-2
Malaria, FVBI, enteric, blood culture & AMR testing (KH); influenza & AFI testing (ID, KH, SG);
surveillance data management (LA)
4
73
4
NAMRU-3
Influenza, blood culture & AMR testing (EG, JO); Influenza PCR/culture & antiviral resistance testing
(32 countries); Joint Biological Agent Identification & Detection System (5 deployed US military
sites-CENTCOM**); zoonotic disease & entomology (EG, DJ); AFI, blood/cerebrospinal spinal fluid
culture & serology testing (AZ, GE); Leishmania PCR & culture (EG, LR); rotavirus testing (6
countries); cholera & other ADD testing (7 countries); FVBI testing (EG, DJ, AZ, GE)
37
42
34
NMRCDPeru
Influenza PCR/culture & antiviral resistance testing support (10 countries); AFI & viral culture &
serology testing (PE, BO, EC, PY); Leishmania PCR, MDR, urine/vaginal PCR-STIs, Rickettsial PCR &
culture (PE); enteric culture, PCR & AMR testing (PE, EC, PY); Alerta electronic disease surveillance
system (PE, PA, EC)
23
102
11
USAMRUKenya
Malaria/MDR, microscopy & PCR, rotavirus, cholera & other ADD testing, arboviral/VHF PCR &
culture, AFIs, blood culture & serology testing, STIs culture (KE); influenza PCR, culture &genotyping
(KE, UG, CM); influenza, AFI, FVBI, cholera & other ADDs (KE, TZ, NG)
7
69
5
PHCR-South Influenza PCR, culture & indirect immunofluorescence assay (US, HN, SV, NI, GT, PA); malaria,
Leishmania, & dengue PCR testing (HN)
4
7
6
Univ Iowa
CEID
JHU/APL
Respiratory & other zoonotic respiratory EID testing & epidemiology (US, TH, KH, NG, RO, MN)
6
~30
6
Influenza military treatment facilities (PIPM) modeling (US); SMS text & ESSENCE Desktop edition
system (PH); Open source Interactive Voice Recognition software surveillance (PE); OpenESSENCE
website software surveillance (US, PE); SMS text (PH)
1
~125
3
Acronyms: MDR, multidrug resistance; FVBI, febrile & vector-borne illnesses; AMR, antimicrobial resistance; AFI, acute febrile illnesses (such as dengue,
leptospirosis and zoonotic infections); PCR, polymerase chain reaction; ADD, acute diarrheal diseases (such as traveler’s diarrhea, campylobacter, shigellosis,
salmonellosis); STIs, sexually transmitted infections, including Neisseria gonorrhea; EID, emerging infectious diseases; PIPM, Pandemic Influenza Prevention
Modeling; SMS, Short Message Service; ESSENCE, Electronic Syndromic Surveillance for Early Notification of Community-based Epidemics.
*Country names are displayed in parenthesis using the International Organization for Standardization (ISO 3166) two-character code (URL:
http://www.commondatahub.com/live/geography/country/iso_3166_country_codes?gclid=CPSnst2e5KQCFQqP5god3xzd8A); Countries column represents the
number where activities have been implemented; U.S. military deployment sites (such as Iraq, Afghanistan) or U.S. Department of State embassies do not
contribute to separate country counts, since they represent overseas locations where U.S. forces and/or civilians are deployed or stationed.
**CENTCOM, U.S. Central Command (forward U.S. troop deployment sites).
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Figure 1 AFRIMS BSL-3 Laboratory Commissioning. On September 16, 2009 (from left to right), Major General Krisada Duangurai, director
general of AFRIMS; U.S. Ambassador Eric John, together with Colonel James Boles, commander of AFRIMS, officiated the ribbon-cutting
ceremony for the AFRIMS BSL-3 laboratory. This facility significantly contributes to the country’s capacity to conduct research and investigate
outbreaks caused by agents, such as avian influenza, chikungunya virus and other endemic diseases throughout Southeast Asia.
Figure 2 Influenza Surveillance Capacity-Building Initiative with Global Viral Forecasting Initiative and University of Buea, Cameroon.
Two biosafety level-2 laboratories were renovated at the Cameroon Army Military Health Research Center in Yaoundé and at the University of
Buea, in cooperation with the Cameroon government and military. These laboratories have the capacity to isolate and characterize human and
animal influenza viruses, as well as other EID pathogens of unknown origin.
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Health Laboratory and also established real-time reverse
transcriptase polymerase chain reaction (rRT-PCR) diagnostic capacity for influenza at a main tertiary-care hospital of the Department of Health within the Visayas
region of the Philippines.
Developing influenza diagnostic capabilities at other
NICs was also supported by the U.S. Naval Medical
Research Unit No. 3 (NAMRU-3) in Afghanistan, Iraq
and Jordan; by the U.S. Naval Medical Research Center
Detachment in Peru (NMRCD-Peru) in the countries of
Colombia, Ecuador, Paraguay and Venezuela; and in
Kenya, by the U.S. Army Medical Research Unit-Kenya.
Finally, in conjunction with the CDC’s Central America
and Panama center, the U.S. Army Public Health Command Region-South (PHCR-South) provided laboratory
technical assistance, reagents and supplies to the Ministries of Health (MoHs) in El Salvador, Guatemala, Honduras, Nicaragua and Panama, resulting in the
certification of the Guatemalan NIC and the testing of
over 5,000 specimens for novel A/H1N1.
In collaboration with the Peruvian Navy, NMRCDPeru has built a robust shipboard disease surveillance
infrastructure with detection capability modeled very
closely on the NHRC shipboard surveillance system.
The early detection aspect of this system involves
equipping participating ships with real-time PCR diagnostic capability for emerging infectious diseases, such
as influenza or adenovirus. Short-term storage of samples allows for more in-depth, follow-up testing at the
laboratory in Lima or at other collaborating regional
laboratories. Since 2007, this system has successfully
identified and responded to numerous outbreaks of
respiratory, gastrointestinal and sexually transmitted
infections among active-duty Peruvian personnel
aboard ships [12]. More recently, this capability was
instrumental in identifying and responding to a large
outbreak of novel A/H1N1 on board a large deck ship
in the Pacific [13].
This investment in laboratory infrastructure development has directly impacted the number of outbreak
investigations that the AFHSC-GEIS network has been
able to support. The capacity-building efforts contributed to outbreak responses in 76 instances in 53 countries, representing every major populated region of the
world, including support for the confirmation of the
first cases of novel A/H1N1 in 14 countries (United
States, Bhutan, Cambodia, Colombia, Djibouti, Ecuador,
Egypt, Kenya, Kuwait, Lao People’s Democratic Republic
(PDR), Lebanon, Nepal, Peru and the Republic of the
Seychelles) [12]. The laboratory infrastructure allows for
acute response capability and the ability to monitor
ongoing epidemics or shifting EID patterns, such as the
identification and continued monitoring of artemisininresistant malaria in Southeast Asia by partners from
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AFRIMS [14] and at the U.S. Naval Medical Research
Unit No. 2 (NAMRU-2) or the search for genetic mutations within influenza viruses that may indicate resistance to antiviral medications.
Training
It is important to recognize that capacity building not
only involves renovating laboratories and providing diagnostic equipment and supplies, but most important,
building human capacity. Through training public health
and laboratory personnel, the physical infrastructure
could be properly leveraged for optimal support of IHR
(2005) compliance. During 2009, AFHSC-GEIS supported 18 partner organizations that conducted 123
training initiatives in 40 countries involving at least
3,130 people, including many host-country personnel, in
direct support of assisting with compliance with IHR
(2005). Significant expansion of training activities was
attained in the areas of pandemic preparedness, outbreak investigation and response, EID surveillance, and
pathogen diagnostic techniques.
By engaging local health and other government officials and civilian institutions in training endeavors, the
U.S. military’s role as a key stakeholder in global public
health has improved; and many opportunities for EIDrelated surveillance, research and capacity-building
initiatives have been leveraged to provide a platform for
public health training, described elsewhere in this supplement [11].
Electronic surveillance initiatives
Electronic disease surveillance, another important component of a comprehensive global public health disease
prevention and control strategy, contributes significantly
to capacity building and support for IHR (2005) compliance in partner countries. Using electronic methods for
data collection and analysis has the potential to improve
the accuracy and timeliness of outbreak detection, as well
as to provide situational awareness during, or in the
aftermath of, an outbreak or pandemic. The AFHSCGEIS network has supported numerous initiatives in
electronic disease surveillance during the past several
years, in partnership with several DoD overseas laboratories, host-country Ministries of Health and Defense
and our technical partner, the Johns Hopkins University
Applied Physics Laboratory (JHU/APL).
AFHSC-GEIS has relied on the extensive experience
that JHU/APL acquired in the design and implementation of the Electronic Syndromic Surveillance for Early
Notification of Community-based Epidemics (ESSENCE)
system [15]. This electronic disease surveillance system,
used worldwide at all DoD military treatment facilities
(MTFs), the U.S. Veterans Health Administration system
and at least 12 states in the United States, served as a
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model for a toolkit approach to deploying electronic
surveillance within the AFHSC-GEIS network. Tools
have been created to enable data collection from the
most sophisticated data sources to remote settings
where data have traditionally been difficult, if not
impossible, to collect. These tools have far-reaching
applicability in any resource-limited setting, whether
overseas or after a disaster in the United States. The following describes some of the efforts that have focused
on adapting electronic or syndromic surveillance techniques to resource-limited settings.
Two electronic surveillance efforts were developed at
AFRIMS in Southeast Asia and optimized in 2009, including a project with the Royal Thai Army (RTA) in remote
border areas, as well as a pilot short message service
(SMS)-based project in the Philippines, part of a joint
effort with JHU/APL and the Cebu City Health Office
(CHO). The Thai Unit-Based Surveillance (UBS) project
commenced in 2001 and originally covered areas along the
Thai-Cambodia border where the Thai MoH did not have
disease surveillance capabilities. The project, developed by
the RTA with support from AFRIMS and AFHSC-GEIS,
reports diseases in both military and local civilian populations by faxing reports or by voice via military radio. In
2009, the Thai-Myanmar border area was added and an
additional 497 personnel were trained. Version 2.0 of the
UBS simplified data collection from 216 symptoms and
categorization into 12 syndromes that are consistent with
the Thai MoH’s reporting requirements. This updated
system added questions about poultry exposure, leptospirosis, novel A/H1N1 infection and chickungunya virus
infection. Although no major outbreaks of disease were
detected by this system in 2009, it continued to provide
situational awareness for the RTA and Thai MoH.
Dengue fever poses a significant health threat in the
Philippines. Current hospital-based surveillance is highly
valid, but poorly suited for rapid identification of dengue
”hot spots” because of delays associated with laboratory
confirmation. To capture this important data for the
purposes of surveillance, a more rapid, but less specific
surveillance method was implemented and compared to
the standard sentinel surveillance system. This pilot
study implements and evaluates a simple dengue surveillance protocol using SMS text messages to send daily,
person-based dengue surveillance data from local Barangay Health Centers (BHCs) to the city health office
(CHO) in Cebu City. The pilot activity was originally
established in five clinics as of March 2009, but was
soon instituted in all BHCs in the city. Beginning July 1,
2009, all BHCs have been identifying all patients reporting to clinic with fever. Each day, BHC personnel send
this information to the CHO, creating a text message
for each patient with fever. The SMS message contains
the date and clinic name, as well as the patient’s name,
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age, gender and symptoms. The message is transferred
into a Microsoft Access© database, cleaned, and starting
July 2010, reviewed in the ESSENCE Desktop Edition
application to identify statistically significant increases in
reported fever cases.
Meanwhile, NAMRU-2 continued to support the optimization of the Early Warning Outbreak Recognition
System (EWORS) at 11 reference and provincial hospitals in the Lao PDR allowing local MoH officials to
monitor the impact and burden of tropical and infectious diseases in the country in real time. The CDC currently funds most of the operating budget for EWORS
in Lao PDR. The system, jointly developed by the Indonesian MoH and NAMRU-2 with AFHSC-GEIS funding,
is also being used in Indonesia as the national reporting
system. EWORS has additionally been used in Cambodia,
Peru and Vietnam, although it is no longer in use in
these countries because local health authorities favored
other surveillance systems.
In South America, NMRCD-Peru supported major
efforts in electronic disease surveillance, including continuation and optimization of Alerta, a public-private
initiative that has revolutionized surveillance for the Peruvian military during the past seven years. The Alerta
system has seen recent expansion to all branches of the
Peruvian military, as well as adoption by the MoH of one
other country in the region—Panama. This system identified 17 outbreaks during 2009, including influenza, dengue, mumps, malaria, hepatitis A and respiratory disease.
Finally, in collaboration with the JHU/APL group,
NMRCD-Peru worked to develop an electronic syndromic surveillance system based on open-source software
for use in resource-limited environments. As a result, the
system can be sustained without continued major investments or software licensing fees. This effort involved the
development of interactive voice response reporting, as
well as building a web-based infrastructure and database
on an open-source version of the ESSENCE system
(OpenESSENCE) in use in the United States. Additionally, NMRCD-Peru supported the systematic evaluation
of these electronic surveillance systems and research on
ways to improve reporting via electronic systems [16].
These electronic surveillance initiatives constitute a
vibrant portfolio that capitalizes on the expertise of the
JHU/APL group and numerous AFHSC-GEIS partners at
overseas laboratories and within host-country Ministries
of Health and Defense. Many of the lessons learned, challenges, successes and failures have been shared within
this network of collaborators, and a harmonized strategy
is emerging to develop and deploy an electronic disease
surveillance system that is modular and responsive to
various needs found in developing settings. This
approach should assist many countries in complying with
IHR (2005) by the 2012 deadline.
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Provision of technical expertise/reference
laboratory support
In addition to supporting laboratory infrastructure
development and new surveillance initiatives, AFHSCGEIS provided technical expertise in support of capacity-building efforts. In 2009, one of the largest such
efforts was the network’s global response to the novel
A/H1N1 influenza pandemic. For example, NAMRU-3
provided training on laboratory techniques for 73 scientists and technical personnel from 32 countries in western and northern Africa, the Middle East, and central
Asia, as well as equipment and reagent support to established NICs in Egypt, Kuwait, Oman, Pakistan, Sudan
and Syria. Support for further viral characterization by
genetic sequencing and antiviral resistance testing was
also performed at NAMRU-3, with reference testing
support by the CDC in Atlanta. This virology diagnostic-testing capacity building of national reference laboratories constituted an essential step in establishing the
capability for H5N1 and novel A/H1N1 detection and
rapid response, and resulted in a better understanding
of the epidemiologic patterns of respiratory viruses circulating in the region. It also represented the first step
toward NIC accreditation and collaboration with the
WHO Global Influenza Surveillance Network in support
of influenza vaccine development. By linking countries
in regional and sub-regional networks and by fostering
participation in WHO missions to assess laboratory testing capacity needs, NAMRU-3 played a direct role in
promoting IHR (2005) compliance.
Working closely with U.S. Central Command and U.S.
Africa Command, NAMRU-3 and the U.S. Navy Environmental and Preventive Medicine Unit No. 2 (NEPMU-2)
provided focused laboratory assessment, training, emergency supplies and quality assurance support to five military, far-forward deployed, influenza testing laboratories in
Southwest Asia and assisted with the deployment of the
Joint Biological Agent Identification and Detection System
(JBAIDS) platform for confirmation of novel A/H1N1
cases in-theater. This capability subsequently proved critical when Expeditionary Medical Forces in Kuwait and
Djibouti were able to identify and respond to novel
A/H1N1 and seasonal influenza outbreaks, respectively.
Network expertise and competence were important in
supporting global influenza testing efforts. For instance,
the AFRIMS-supported laboratory in the Philippines
was designated by the Philippine NIC as the only other
facility authorized to conduct novel A/H1N1 testing, in
support of central and southern regions of the country
(specifically, Mindanao and Visayas).
Military-to-military (mil-mil) partnerships
Growing collaborative military-military partnerships and
surveillance exchanges among global network partners
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and foreign military counterparts continued to be an
area of high interest and priority for AFHSC-GEIS. The
network currently supports active military partnerships
in 14 countries. These partnerships resulted in a number of collaborative response activities that supported
foreign military partners, multinational peacekeepers
and observers in joint exercises and missions.
The late spring and summer outbreaks of novel
A/H1N1 in military treatment facilities throughout
Europe resulted in collaboration between Landstuhl
Regional Medical Center and PHCR-Europe and the
German Military Reference Laboratory. The long-standing relationship between the U.S. European Command
and the German Army’s Public Health Service helped
assist in disseminating confirmed results through weekly
surveillance reports sent to military clinicians, hospital
commanders, and other public health officials within the
U.S. military and the local German public health infrastructure. This arrangement greatly aided the U.S.
European Command’s ability to conduct surveillance for
novel A/H1N1 within the European military community
and assisted German government officials in monitoring
the level of disease within their country.
Efforts have been established to collaborate on more
expansive and cross-cutting surveillance systems with military partners in Poland and Singapore. These efforts
include a wide spectrum of surveillance from electronic
early detection systems and routine laboratory-based sentinel surveillance to robust pathogen discovery initiatives
and focused public health research endeavors. Collaboratively, these efforts have developed significantly during the
past year and have helped serve as a model for other
AFHSC-GEIS partners to engage their regional foreign
military counterparts. These mil-mil partnerships with
allied countries allow for open collaboration, capacity
building and transparent dialogue between partner countries, and thus have the potential to develop a meaningful
framework to better understand disease dynamics among
military populations in different parts of the world. To
further foster opportunities for these mil-mil partnerships,
AFHSC-GEIS is working with the International Congress
on Military Medicine and the WHO by facilitating educational opportunities with regard to IHR (2005) and creation of a portfolio of robust epidemiological tools and
training that member countries can access as needed [17].
Future directions and challenges
Significant progress was attained in expansion of worldwide EID surveillance and response initiatives in fiscal
2009 through the capacity-building efforts of the
AFHSC-GEIS network described above. At this juncture,
however, it is necessary to achieve realistic goals in terms
of maturation, standardization and unification of the division’s global surveillance efforts. This can best be
Sanchez et al. BMC Public Health 2011, 11(Suppl 2):S4
http://www.biomedcentral.com/1471-2458/11/S2/S4
accomplished by pursuing the following strategic goals:
1) adopting objective metrics of evaluation, such as timeliness of disease detection and reporting to higher levels,
proportion of sites submitting timely weekly or monthly
reports, proportion of investigated outbreaks with confirmed laboratory results, and proportion of confirmed
outbreaks with nationally recommended public health
response [18]; 2) ensuring future standardization of
genetic and molecular-based testing platforms (e.g., PCRbased assays) across the network of partners; 3) establishing electronic sequence data repositories for more effective information sharing with the CDC, WHO and local
regional health authorities (especially for influenza and
other respiratory pathogens); 4) continuing emphasis on
collaborative work with host-country partners to
empower them to reach IHR (2005) capacity-building
milestones by 2012; and, 5) achieving standardized
reporting schemes for all AFHSC-GEIS partners in the
areas of influenza, enteric diseases, febrile and vectorborne illnesses, sexually transmitted infections, and antimicrobial resistance monitoring. In this manner, the
AFHSC-GEIS network will continue to contribute to the
global efforts in disease control and prevention through
the DoD’s laboratory-based surveillance and by enhancing harmonization of efforts with other key USG stakeholders, such as the U.S. Department of Health and
Human Services, the U.S. Agency for International Development and the U.S. Department of State.
Many challenges exist to building capacity for public
health in resource-limited settings, including achieving sustainability of efforts after support is withdrawn, containing
the departure of highly-trained, capable scientists after
training, and minimizing the duplication of efforts among
multiple sponsor agencies within the USG and with other
organizations. Data sovereignty and data sharing are also
key issues that require transparency on the part of both the
sponsor and recipient in order to optimally conduct disease
surveillance that satisfies the spirit of IHR (2005). Solutions
to many of these challenges are sometimes difficult and frequently require continuous re-evaluation of best of practice
solutions for individual settings.
Through the development of active, mutually supportive relationships with local health officials and the establishment of important protocol-driven clinical and
laboratory surveillance projects, AFHSC-GEIS supported
scientists have become relevant stakeholders within hostcountry public health communities and are able to continue to work in the critical development of surveillance,
laboratory and communications infrastructure within
partner countries. In addition to the IHR (2005), the
AFHSC-GEIS global network recognizes the recently
released National Strategy for Countering Biological
Threats (PPD-2) as another guiding framework for alignment of our program with the larger USG initiatives [19],
Page 8 of 9
keeping the maintenance of the U.S. military’s health
(known as “Force Health Protection”) as our unique
niche in the setting of improving global public health.
Meaningful public health initiatives taking place in any
one of the partner countries within the AFHSC-GEIS
global network must aim for incremental, albeit sustainable, development of capacity on behalf of their partner
host countries and do so in line with the specific PPD-2
objectives and IHR (2005) competencies. In this manner,
small improvements in capacity, improved testing abilities, and ultimately, compliance with reporting will lead
to benefits for the health of U.S. servicemembers and for
the health of the world.
Acknowledgements
#AFHSC-GEIS Capacity Building Writing Group: Clara J Witt1, Nisha N Money1,
Joel C Gaydos1, Julie A Pavlin2, Robert V Gibbons2, Richard G Jarman2, Mikal
Stoner2, Sanjaya K Shrestha2, Angela B Owens3, Naomi Iioshi3, Miguel A
Osuna3, Samuel K Martin4, Scott W Gordon4, Wallace D Bulimo4, Dr. John
Waitumbi4, Berhane Assefa4, Jeffrey A Tjaden5, Kenneth C Earhart5, Matthew
R Kasper6, Gary T Brice6, William O Rogers6, Tadeusz Kochel7, Victor Alberto
Laguna-Torres7, Josefina Garcia7, Whitney Baker8, Nathan Wolfe9, Ubald
Tamoufe9, Cyrille F Djoko9, Joseph N Fair9, Jane Francis Akoachere10, Brian
Feighner11, Anthony Hawksworth12, Christopher A Myers12, William G
Courtney13, Victor A Macintosh13, Thomas Gibbons13, Elizabeth A Macias13,
Max Grogl14, Michael T O’Neil14, Arthur G Lyons14, Huo-Shu Houng14,
Leopoldo Rueda14, Anita Mattero14, Edward Sekonde14, Rosemary Sang15,
William Sang15, Thomas J Palys16, Kurt H Jerke16, Monica Millard17, Bernard
Erima17, Derrick Mimbe17, Denis Byarugaba18, Fred Wabwire-Mangen18,
Danny Shiau19, Natalie Wells19, David Bacon19, Gerald Misinzo20, Chesnodi
Kulanga20, Geert Haverkamp20, Yadon Mtarima Kohi21, Matthew L Brown22,
Terry A Klein22, Mitchell Meyers22, Randall J Schoepp23, David A Norwood23,
Michael J Cooper24, John P Maza24, William E. Reeves25, and Jian Guan25.
The authors wish to thank the numerous individuals who perform
surveillance as part of the AFHSC-GEIS global network, including all
individuals in the Ministries of Health and Ministries of Defense of our
partner nations whose efforts have contributed to the success of the
network.
Disclaimer
The opinions stated in this paper are those of the authors and do not
represent the official position of the U.S. Department of Defense, local
country Ministries of Health, Agriculture or Defense, or other contributing
network partners.
This article has been published as part of BMC Public Health Volume 11
Supplement 1, 2011: Department of Defense Global Emerging Infections
Surveillance and Response System (GEIS): an update for 2009. The full
contents of the supplement are available online at
http://www.biomedcentral.com/1471-2458/11?issue=S2.
Author details
Armed Forces Health Surveillance Center, 503 Robert Grant Avenue, Silver
Spring, MD 20910, USA. 2Armed Forces Research Institute of Medical
Sciences, 315/6 Rajavithi Road, Bangkok, Thailand 10400. 3U.S. Army Public
Health Command Region-South, Building 2472, Schofield Road, Fort Sam
Houston, TX 78234, USA. 4U.S. Army Medical Research Unit-Kenya, U.S.
Embassy, Attn: MRU, United Nations Avenue, P.O. Box 606, Village Market
00621 Nairobi, Kenya. 5Naval Medical Research Unit Number 3, Extension of
Ramses Street, Adjacent to Abbassia Fever Hospital, Postal Code 11517,
Cairo, Egypt. 6Naval Medical Research Unit Number 2, Kompleks
Pergudangan DEPKES R.I., JI. Percetakan Negara II No. 23, Jakarta, 10560,
Indonesia. 7Naval Medical Research Center Detachment-Peru, Centro Medico
Naval “CMST,” Av. Venezuela CDRA 36, Callao 2, Lima, Peru. 8Department of
Environmental and Global Health, College of Public Health and Health
Professions, University of Florida, Post Office Box 100188, Gainesville, FL
32610, USA. 9Global Viral Forecasting Initiative, One Sutter Street, Suite 600,
San Francisco, CA 94104, USA. 10University of Buea, Department of
1
Sanchez et al. BMC Public Health 2011, 11(Suppl 2):S4
http://www.biomedcentral.com/1471-2458/11/S2/S4
Biochemistry and Microbiology, Faculty of Science, Post Office Box 63, Buea,
South Western Province, Cameroon. 11Johns Hopkins University Applied
Physics Laboratory, 11100 Johns Hopkins Road, MP2-160, Laurel, MD 207236099, USA. 12Naval Health Research Center, 140 Sylvester Road, San Diego,
CA 92106, USA. 13U.S. Air Force School of Aerospace Medicine, Public Health
and Preventive Medicine Department, 2513 Kennedy Circle, Building 180,
Brooks City-Base, TX 78235-5116, USA. 14Walter Reed Army Institute of
Research, Building 503, 503 Robert Grant Avenue, Silver Spring, MD 209107500, USA. 15Kenyan Medical Research Institute, Mbagathi Post Office Box
54840, 00200, Nairobi, Kenya. 16Landstuhl Regional Medical Center, CMR 402,
Box 483, APO AE 09180, USA. 17Makerere University Walter Reed Project, Plot
42, Nakasero Road, Post Office Box 16524, Kampala, Uganda. 18Makerere
University, Faculty of Veterinary Medicine & Medicine, Post Office Box 16524,
Kampala, Uganda. 19Navy Environmental and Preventive Medicine Unit
Number 2, 1887 Powhatan Street, Norfolk, VA 23511-3394, USA.
20
PharmAccess Foundation, Skyway Building, Third Floor, Plot Number 149/
32, Corner of Ohio Street/Sokoine Street, Post Office Box 635, Dar es Salaam,
Tanzania. 21Tanzania People’s Defence Forces, Defence Forces Headquarters
Medical Services, Post Office Box 9203, Dar es Salaam, Tanzania. 22U.S. Army
Medical Department Activity & 65th Medical Brigade, Korea, Unit 15281, Box
769, APO AP 96205-5281. 23U.S. Army Medical Research Institute of Infectious
Diseases, Diagnostic Systems Division, 1425 Porter Street, Fort Detrick, MD
21702-5011, USA. 24U.S. Army Public Health Command Region-Europe,
Building 3810, CMR 402, Box 808, APO AE 09180. 25U.S. Army Public Health
Command Region-Pacific, Building 715, Camp Zama, Japan, Unit 45006, APO
AP 96343-5006.
Page 9 of 9
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doi:10.1186/1471-2458-11-S2-S4
Cite this article as: Sanchez et al.: Capacity-building efforts by the
AFHSC-GEIS program. BMC Public Health 2011 11(Suppl 2):S4.
Competing interests
To the best knowledge of the authors, there are no competing interests.
Published: 4 March 2011
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